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Home My WebLink About2015-152 Aging - NC Division of Aging and Adult Services - Amendment to Contract dated 3-22-2013 M Please return this copy to the Clerk to the Board's _ office Contract Number 00028582,Amendment Number 2/Page 1 of 12 f rmanent agenda file. Ao r� AMENDMENT This Agreement amends the contract bearing the effective date of 3/22/2013 between the North Carolina Department of Health and Human Services, Division of Aging and Adult Services, hereinafter referred to as the"Division"and Orange County, hereinafter referred to as the"Contractor." This Amendment is hereby effective on 3/20/2015. As provided for under the terms of this contract,the Division and the Contractor agree to amend the following contract provisions: 1. Reference"Effective Period": The termination date of 3/21/2015 is changed to 6/30/2015 2. Reference"Contractor's Duties": The Contractor shall provide the amended services as described in the scope of work. 3. Reference"Division's Duties": The total amount paid by the Division to the Contractor is not being changed. This is a no cost amendment. The contract amount remains$50,000. . The total amendment amount is$0. The total contract amount is$50,000. All other terms and conditions as set forth in the original contract document shall remain in effect for the duration of this Agreement. Signatures follow on next page NCDHHS ACT2007 (Amendment Template)(Rev. 9/12) Contract Number 00028582,Amendment Number 2/Page 2 of 12 In Witness Whereof,the Contractor and the Division have executed this contract in duplicate originals, with one original being retained by each party. Orange County Signature r Date Bonnie B. Hammersley County Manager Printed Name Title WITNESS igna ure Date `m e I I L'�eau-Hv t Printed Name Title Division of Aging and Adult Services, North Carolina Department of Health and Human Services Signalt Date Suzanne P. Merrill Director Printed Name Title NCDHHS ACT2007(Amendment Template)(Rev. 9/12) Contract Number 00028582,Amendment Number 2/Page 3 of 12 SCOPE OF WORK PURPOSE This amendment changes the contract end date from March 21, 2015 to June 30, 2015 to allow the contractor additional time to complete the requirements outlined under this contract. No additional funding is provided-the contract amount remains the same. All deliverables and reporting requirements outlined in the original Scope of Work continue to apply. Scope of Work(Rev. 06/11) Contract Number 00028582,Amendment Number 2/Page 4 of 12 PERFORMANCE MEASURES CHART The Department of Health and Human Services uses performance measures rubrics as a tool to determine the success of a project and how well services and products are being delivered. Together they enable the Department to gauge efficiency, determine progress toward desired results and assess whether the Department is on track with meeting its goals. The contractor shall adhere to all of the performance requirements/standards in the scope of work, including performance measures in the performance measures chart below. Measure Output pa Annual -Type Measure Products/materials available for replication for use with other Chinese-speaking populations d ear? 1 Increase 0 2 Vendor Products Vendor Product Annually '.Mea$uIe .aa Outcome Quarterly Meaiire. Number of caregivers served by peer volunteers 1 Increase " 0 e 15 dor Reports Vendor Reports Ir ually y Performance Measures(Rev.012) Contract Number 00028582,Amendment Number 2/Page 5 of 12 Measure Outcomefei Annual Type � � . Measure Impact of caregiver peer volunteer on caregiver stress/burden Other `S dry 1i:X x-Bsefiin�e,` 0 Tare 1ue;ti Increase in respondants who experience less stress in caregiving Waa;'ior " ' Caregiver Surveys . dl[ec "`�iia Vendor Reports rya- i Annually Performance Measures (Rev.4//12) Contract Number 00028582, Amendment Number 2/Page 6 of 12 LINE ITEM BUDGET This begins the line item budget for year 1 hake; °gY;Fna °md'utit `tee. L MA"@�`.�. •iii'f'� 4' .(V'•� '�\`�,\i::;,. '!:�:>`t: .f4.a{.Y. Salary\Wages $18,074.00 $0.00 $18,074.00 Fringe Benefits $2,228.00 $0.00 $2,228.00 Other $0.00 $0.00 $0.00 Supplies and Materials Other $990.00 $0.00 $990.00 Supplies and Materials Other $420.00 $0.00 $420.00 Supplies and Materials Other $100.00 $0.00 $100.00 �I Supplies and Materials Other $1,000.00 $0.00 $1,000.00 Equipment IT $1,814.00 $0.00 $1,814.00 Travel Contractor $374.00 $0.00 $374.00 Staff Line Item Budget Detail(08/11) Contract Number 00028582,Amendment Number 2/Page 7 of 12 �. � '1`:'r,`•�•�i'�'+,:'i'xk,'+,z„. s.'e�3".' 'y�,a",y: _'.S.;.rS.:.•i^. `e McintChan- „A .:>nfba F�nafyAtstini'?>. Repair and Maintenance $0.00 $0.00 $0.00 Staff Development $0.00 $0.00 $0.00 Dues and Subscriptions $0.00 $0.00 $0.00 Subcontracts and Grants $0.00 $0.00 $0.00 Match $0.00 $0.00 $0.00 Cost Per Service $0.00 $0.00 $0.00 $25,000.00 $0.00 $25,000.00 Indirect Cost $0.00 $0.00 $0.00 Im MENEM $25,000.00 $0.00 $25,000.00 Em NNW i I d y, $0.00 $0.00 $0.00 Line Item Budget Detail(08/11) Contract Number 00028582,Amendment Number 2/Page 8 of 12 al 'ssac::t�•:;.M!�t � ,5: '" ..s�.••".,'; rd:+s.ag<: iKayoY A,� =; �ti.,:F. $0.00 $0.00 $0.00 0.0000 0 0010 $0.00 $0.00 $0.00 Line Item Budget Detail(08/11) Contract Number 00028582,Amendment Number 2/Page 9 of 12 This begins the line item budget for year 2 ► . r .glltt Wt Eri; m4unt-< S $20,986.00 $0.00 $20,986.00 Fringe Benefits $2,594.00 $0.00 $2,594.00 Other $0.00 $0.00 $0.00 Supplies and Materials Other $250.00 $0.00 $250.00 Supplies and Materials Other $400.00 $0.00 $400.00 Supplies and Materials Other $420.00 $0.00 $420.00 Supplies and Materials Other $100.00 $0.00 $100.00 Repair and Maintenance $0.00 $0.00 $0.00 Staff Development $0.00 $0.00 $0.00 Media/Communication Advertising $250.00 $0.00 $250.00 Line Item Budget Detail(08/11) Contract Number 00028582,Amendment Number 2/Page 10 of 12 •� �v"',n'`�xj°a�.`e'�' �. :�ro'":.�>• 43»: z.e:iy:.,s+a�.• '9E v��:i�'cz�''w .. `'d tt < b eAiliiutit ih.: lrriaiit' & P A%$.:AF£J'L?:^.+bin.ng>�'�&ea�`.",.'•�.>:....AM.,'�k w(.•S'.,.>.`: t;. Dues and Subscriptions $0.00 $0.00 $0.00 Subcontracts and Grants $0.00 $0.00 $0.00 Match $0.00 $0.00 $0.00 Cost Per Service $0.00 $0.00 $0.00 $25,000.00 $0.00 $25,000.00 Indirect Cost $0.00 $0.00 $0.00 $25,000.00 $0.00 $25,000.00 ZA I 7mm ; $0.00 $0.00 $0.00 Ism INK= $0.00 $0.00 $0.00 Line Item Budget Detail(08/11) Contract Number 00028582, Amendment Number 2/Page 11 of 12 Wed az •:d '�''=k�' >� ":'�° ti. i, .us�',{.ztr,�! 3.; F.°�� Ys� �'b�L 's:J'�w ':.�'Y•:;': 0 $0.00 0.0000 0 0% $0.00 $0.00 $0.00 I II Line Item Budget Detail(08/11) State CfabtHkAt`>lomber 00028582,Amendment Number 2/Page 12 of 12 Contractor Certifications Required by North Carolina Law Instructions The person who signs this document should read the text of the statutes listed below and consult with counsel and other knowledgeable persons before signing. The text of each North Carolina General Statutes can be found online at: • Article 2 of Chapter 64: http://www.ncga.state.nc.us/EnactedLezislatio.n/Statutes/PDF/By.Aiticle/Chapter 64/Article 2.udf • G.S. 105-164.8(b): http://www ncga state nc us/EnactedLegislation/Statutes/PDF/BySection/Chgpter 105/GS 105-164.8.pdf • G.S. 143-48.5: http•//www ncga state nc us/EnactedLepislation/Statutes/HTML/BySection/Chapter 143/GS 143-48.5.1itml • G.S. 143-59.1: http•//www ncga state nc us/EnactedLegislation/Statutes/PDFBySection/ChVter 143/GS 143-59.1.pdf • G.S. 143-59.2: http•//www ncga state nc us/EnactedLegislation/Statutes/PDF/BySection/ChUter 143/GS 143-59.2.pdf • G.S. 147-33.95(g): http://www ncga state nc us/EnactedLegislation/Statutes/Hnfi,BySection/Chapter 147/GS 147-33.95.html Certifications (1) Pursuant to G.S. 143-48.5 and G.S. 147-33.95(8), the undersigned hereby certifies that the Contractor named below, and the Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC General Statutes, including the requirement for each employer with more than 25 employees in North Carolina to verify the work authorization of its employees through the federal E-Verify system." E-Verify System Link: www.uscis.gov (2) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not an "ineligible Contractor"as set forth in G.S. 143-59.1(a)because: (a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or more of the conditions of G.S. 105-164.8(b);and (b) [check one of the following boxes] ® Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven country"as set forth in G.S. 143-59.1(c)(2)after December 31,2001;or ❑ The Contractor or one of its affiliates has incorporated or reincorporated in a"tax haven country" as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not the principal market for the public trading of the stock of the corporation incorporated in the tax haven country. (3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors, or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years immediately prior to the date of the bid solicitation. (4) The undersigned hereby certifies further that: (a) He or she is a duly authorized representative of the Contractor named below; (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor;and (c) He or she understands that any person who knowingly submits a false certification in response to the requirements of G.S. 143-59.land-59.2 shall be guilty of a Class I felony. Orange County Department on Aging Contractor's Name Q�� . /, �;4� Si toe of Contractor's Auth6fized Agent Date LIZ I.Tyler Director Printed Name of Contractor's Authorized Agent Title Z85—e�Signature of ness Da e Mary E.Fraser Administrator Printed Name of Witness Title The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document immediately thereafter. Contractor Certifications Required by North Carolina Law(Rev.10/2014) Page 1 of I